-urticaria

SUBJECT: Micro / Para

Lecturer: Dra. Reyes
-early leukocytosis and eosinophilia
-irregular fever Topic: Liver Flukes
Date: Feb. 28, 2008
-more or less persistent diarrhea
-marked anemia TransGrp: 18-20, 24
-hemoglobinuria
Liver Flukes -cholelithiasis: common complication

Pharyngeal fasciolasis or halzoun

Family Fasciolae
1. due to ingestion of infected raw sheep and goat livers
2. adult worm lodges temporarily in the pharyngeal mucosa
-relatively large distomes with he ventral sucker (acetabulum) close to causing:
the oral sucker
-tegument often spinose a. edematous congestion of the soft palate, pharynx,
-testes usually branched larynx, nasal fossae, eusachian tube 
-vitellaria filling much of the lateral fields and confluent posterior to the suffocation
testes b. dyspnea
-uterus short c. deafness
-eggs large and undeveloped when laid d. asphyxiation
-species ha are parasites of man
-fasciola hepatica (liver) Diagnosis
-f. gigantica (liver) Clinical- based on:
-f. buski (intestinal) -biliary symptoms
-moderate to high eosinophilia
Fasciola Hepatica -eating watercress as a green salad

-common name: sheep liver fluke Laboratory

-dse produced: fasciolasis hepatica, sheep liver rot, pharyngeal -recovery of the eggs in the patient’s stool or from duodenal or biliary
fasciolasis or halzoun tract drainage
-geographic distribution: has a cosmopolitan distribution and prevalent -serodiagnosis: helpful but not adapted for routine diagnosis
in sheep raising countries
Ova
Morphology -large, oval, yellowish brown operculated egg
-large size: 20 to 30 m by 8 to 13 mm -measures 130 to 150 u by 63 to 90 u
-flat, leaf shaped with characteristic shouldered appearance from its -unsegmented at oviposition
cephalic cone
-oral and ventral suckers of equal size on the cephalic cone Differential Diagnosis
-intestine with numerous diverticula -acute hepatitis of other etiology
-highly dendritic testes in tandem formation -cholecystitis
-diffusely branched vitellaria in lateral and posterior portions of the -cholelithiasis
body -cirrhosis resulting from other causes
-short convoluted uterus
False fasciolasis- due to ingestion of infected livers with passage of
Pathology eggs in the feces
1. Acute or invasive phase- period during which the fluke
migrates from the intestine to the liver and its burrowing Keep the patient on a liver free diet for 3 days or more
through the liver parenchyma False fasciolasis- eggs no longer seen
a. No significant change from the intestine to the liver True fasciolasis- eggs can still be seen
i. Parasite may wander or be carried by Epidemiology
blood after penetrating a blood vessel to -definitive hosts are herbivores like sheep
ectopic sites such as lungs, -man is an accidental final host
subcutaneous tissues, brain and the -1st intermediate host- lymneid snail
orbit  abscesses or fibrotic lesions a. lymnaea philippinensis
b. Migration to the liver parenchyma- traumatic and b. lymnea swinhoe- 1st IH in Taiwan
necrotic lesions -2nd intermediate host- aquatic vegetation (watercress)
2. Chronic or latent phase- period when the parasite has -humans contract the disease by ingesting plants such as watercress
already reached the bile ducts or possibly water containing the encysted metacercaria
a. Obstruction in the vessel -herbivores or omnivores acquire the infection in low, damp pastures,
b. Inflammatory and adenomatous changes of the where the vegetation is infested with metacercaria
biliary epithelium
c. Fibrosis of the ducts Treatment
d. Pressure atrophy of the liver parenchyma -bithionol (dicholorophenol): 30 to 50 mg/kg per body weight on
e. Intensive periductal fibrosis alternate days to complete 10 to 15 doses
f. Heavy infections -dehydroemetine hydrochloride: 1 mg per kg daily intramuscularly for
i. Erosion of the epithelium 10 days
ii. Young worms wander back into the liver -emetine hydrochloride: 30 mg daily for 17 to 18 days IM or 40 mg
1. to produce abscess pockets daily to a total of 5 mg/kg body weight
2. to seed the vital liver tissue -hexachloroparaxylene: favorable results as reported from Russia
with their eggs -praziquantel: probably effective as in other liver fluke infections

Symptomatology Preventive Measures

-colic and obstructive jaundice -thorough washing or cooking of vegetables
-coughing and vomiting -boiling of water in areas where the infection is endemic
-generalized abdominal rigidity
-acute epigastric pain and tenderness Control Measures
-elimination of the snail IH
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-killing the parasites in the reservoir hosts by chemotherapy
Fasciola Gigantica
-common name: giant liver fluke
-dse produced: fasciolasis gigantica
-geographic distribution: parasite of herbivores mammals particularly
camels, wild hogs, cattle and water buffalo in Africa, Asia, and Hawaii
Differs from F.hepatica
-more elongated or lanceolate
-cephalic cone is shorter and less prominent
-ventral sucker is large
-testes are more anterior in position
-shoulders are particularly lacking
-eggs are larger
Family Opistorchiidae
-parasites of the bile ducts and gall bladder
-small to medium sized, usually elongate and relatively delicate with
weakly developed suckers
-testes located posteriorly may be branched or lobed
-ovary is near midbody
-coiled uterus fills the area between the ovary and ventral sucker
-eggs are small and are fully embryonated
Clonorchis Sinensis
-common name: Chinese liver fluke
-dse produced: clonorchiasis
-geographic distribution:
-an important parasite of humans in the Far East,
- parasite of fish eating mammals and humans in Japan,
China, South Korea, Formosa, and Vietnam
Morphology
-flat, spatulate, aspinous, flabby, transparent, gray worm tapering
anteriorly and somewhat rounded posteriorly
-measures 12 to 20 mm (10 to 25 mm) by 3 to 5 mm
-ventral sucker smaller than oral sucker
-long intestinal ceca extending to the posterior end
-large deeply lobulated or branched testes in tandem formation in the
posterior third of the body
-small, slightly lobate ovary anterior to the testes in the midline
-loosely coiled uterus arising from the ootype ending in the common
genital pore
-minutely follicular vitellaria in the lateral midportion of the body
Pathology
-distal bile ducts are irritated mechanically and by its toxic secretions
-slight leukocytosis and eosinophilia in early infection
-enlarged tender liver
-bile ducts thicken and become dilated and tortous
-adenomatous proliferation of the biliary epithelium
-fibrosis and destruction of hepatic parenchyma
-liver function is impaired although SGPT and SGOT are normal
Cholangiocarcinoma of the Liver- severe chronic infection may lead to
marked pericholangitic fibrosis and finally multifocal cholangiocellular
carcinoma of the liver
Symptomatology
-light infections: produce only mild symptoms or go unnoticed
-moderate infections: indigestion, epigastric discomfort unrelated
meals, weakness, loss of weight
-heavy infections: complicated by cholelithiasis and bouts of pyogenic
cholangitis
Epidemiology
-man is the definitive host
-1st IH: operculate snails of several genera including Alocinma and
Parafossarulus, Bithynia (Bulimus), Semisulcospira, Melanoides
tuberculatus
-2nd IH: fresh water fish of the family Cyprinidae, Ctenopharyngodon
idellus
-humans are usually infected by:
-eating uncooked fish containing the infective metacercariae
-ingestion of the cysts in drinking water
Diagnosis
Clinical-suggestive in patients from endemic areas with:
-history of eating uncooked fish
-symptoms of biliary tract disease
-intermittent jaundice
-bouts of fever
-RUQ pain
Laboratory
-finding the characteristic eggs in the feces or biliary drainage or
duodenal aspiration
-eggs to be differentiated from opistorchid and heterophyid flukes
Ova
-broadly ovoid, 29 by 16 u
-has a moderately thick, light yellowish brown shell
-at the smaller end is a distinct convex operculum which fits into a
rimmed extension of the shell
-at the thicker posterior end is a small median protuberance
Treatment
-chloroquine diphosphate: 250 mg TID for 6 weeks with treatment
failure and side effects including optic neuropathy
-praziquantel: 25 mg/kg TID for 2 consecutive days or 75 mg/kg in 3
doses 4 to 6 hours apart, no treatment failure and only mild side effects
(headache and dizziness)
-heavy infections complicated by obstructive jaundice:
-cholecystectomy with choledocholithotomy
-exploration of the common duct
-drainage procedure such as sphincteroplasty or
choledochoduodenostomy
Preventive Measures
-thorough cooking of all freshwater fish
Control Measures
-education of the public to break the habit of eating raw fish after
seasoning with condiments
-stopping the seeding of fish culture ponds
-sterilization of human feces by storage or by the addition of
ammonium sulfate
-human and animal feces should not be disposed in bodies of water
Opistorchis Sinensis
-common name: cat liver fluke
-disease produced: opistorchiasis felineus
-geographic distribution:
-prevalent in eastern and southeastern Europe and Asiatic
areas of the former USSR
-found in humans in the highly endemic areas of Poland and
the Dnieper, Donetz and Desna basins
Morphology
-lancet in shape 7 to 12 mm by 2 to 3 mm
-rounded posteriorly and attenuated anteriorly
-thin and transparent, reddish bile colored
-has a smooth integument
-two suckers equal in diameter, oral sucker subterminal
-two testes lobed and situated obliquely to each other in the posterior
fourth of the worm
-ovary small, oval or slightly lobed is median in position just in front of
the anterior end of the bladder
-vitellaria consist of numerous transversely compressed follicles
disposed in the lateral fields in the midline third of the body
-uterus: an intricately coiled tubule from the ootype that proceeds
anteriad
Pathology
-inflammatory and proliferative changes of the biliary epithelium
-fibrosis of the distal biliary vessels
-pathologic changes may extend to the proximal bile ducts and gall
bladder  periportal fibrosis
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 Symptomatology
Symptomatology -mild to moderate infections: few symptoms
-light infections: asymptomatic -heavy infections:
-moderate infections: -abdominal distress
-moderate, painful enlargement of the liver -epigastric pain
-passive congestion of the spleen -generalized malaise
-icterus
-local eosinophilia in the wall of the bile ducts Epidemiology
-heavy infections: -definitive hosts: civet cat, cat, dog and other fish eating mammals
-invade the pancreas with digestive disturbances -accidental final host: man
-bile stones may form around eggs as nuclei and cause -1st IH: snails (Bithynia goniumphalus, B funiculate, B laevis)
cholecystitis with colic -2nd IH: freshwater fish (Punteus orphoides, Hampala dispar,
-loss of appetite as patient becomes toxic Cyclocheilichthys siaja)
-scar tissue around the bile ducts encroaches on liver cells -infection is acquired by eating uncooked fish containing the infective
and portal vessels  collateral venous circulation, edema of the face metacercariae
and limbs and at times ascites
Laboratory Diagnosis
Epidemiology -finding eggs in feces or duodenal aspirates: eggs are relatively short
-definitive hosts: cats, dogs, fox, wolves, seals and broad with a length of 26.7 um and breadth of 15 um
-accidental final host: man -ultrasonography: to screen for the presence of cholangiocarcinoma
-1st IH: amnicolid snail Bithynia (Bulimus) leachi
-2nd IH: freshwater fish (cyprinoid fish), Tinca tinca, Idus melanotus, Treatment
Barbus barbus, Cyprinus carpio (Taiwan), Abramis brama, A sapa, -praziquantel: 25 mg/kg body weight 3x daily for 2 days
Alburnus lucidus, Aspius aspius, Blicca bjorkna, Leuciscus rutilis and
Scardiinius erythopthalmus Prevention and Control
-the infection is acquired by eating raw or insufficiently cooked fish -same as O felineus and C sinensis
harboring the metacarcariae
-intermediate snail hosts are infected by feces deposited on sandy Family Dicrocoellidae
shores and washed into streams
-small o medium sized flukes that live in the bile or pancreatic ducts of
Laboratory Diagnosis birds and mammals
-recovery of the ypical eggs in the stool or by duodenal intubation -elongate with well developed suckers
-elongate, ovoid in shape with an operculum that fits into a -notable feature: position of the testes anterior to the ovary
thickened rim of the shell proper -eggs are small, with a thick brown shell and embryonated when laid
-light yellowish brown and are about 3 times as long as
broad Dicrocoelium Dendriticum
-a minute tubercular thickening at the posterior end
-has a miracidium when laid -common name: lance fluke
-resembles Chlonorchis sinensis but: -dse produced: dicrocoeliasis
-are narrower and have more tapering ends -geographic distribution: has a cosmopolitan distribution in sheep and
-a pointed terminal knob other herbivore in Asia, Africa, Europe, and North and South America
-a less conspicuous opercular
Morphology
Treatment -slender, lancet-shaped, flat transparent, aspinous body 5 to 15 mm by
-praziquantel: 40 mg/kg body weight in a single dose after a meal 1.5 to 2.5 mm
Side effects: abdominal pain, vomiting, diarrhea, lassitude, -acetabulum lies at the beginning of the second fifth of the body
myalgia, headache, and rashes -two large, slightly lobed testes situated obliquely to each other anterior
to the small subglobose ovary just behind the ventral sucker
Prevention -voluminous uterine coils in the posterior thirds of the worm
-cooking of fish or abstain from eating raw or inadequately cooked fish -subglobose ovary lies to the right of the midline and somewhat
-sanitary excreta disposal not effective: reservoir hosts and man anterior to the equator of the worm
pollute the waters containing the IH -discrete vitelline follicles occupy lateral fields in the midline of the body
Opistorchis Vivernini Pathology
-same as F hepatica
-dse produced: Opistorchiasis vivernini -in animals
-geographic distribution: an important parasite in northeastern Thailand -enlargement of the bile ducts
and in the northernmost province of Udorn -hyperplasia of the biliary epithelium
-formation of the periductal fibrous connective tissue
Morphology -atrophy of the liver cells
-can be distinguished from O felineus: -portal cirrhosis in heavy infections
-greater proximity of is ovary and testes, both of which are -in humans
deeply lobulated -hepatic changes are less pronounced
-aggregation of is vitellaria into a few clusters of glandular
material Symptomatology
-esophagus is elongated -in humans
-digestive disturbances
Pathologic Changes -flatulence
-dilatation and thickening of bile duct walls -vomiting
-presence of stones and sludge in the gall bladder -biliary colic
-hyperplastic biliary epithelium from presence of worms -chronic constipation or diarrhea
-further simulated by nirosamines in local fermented foods or by -enlarged liver
nitrosocompounds produced by activated macrophages in chronically -systemic toxemia less pronounced than in fasciolasis
affected tissues
-striking association with cholangiocarcinoma Epidemiology
-principal definitive host: sheep and other herbivores

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-accidental final host: man
-1st IH: land snails of the genera Abida, Cochlicopa, Helicella and
Zebrina
-2nd IH: ants (Formica fusca)
-infection of the mammalian definitive host and man is by ingestion of
ants harboring the metacercaria

Laboratory Diagnosis
-finding the eggs consistently in the feces and duodenal drainage
-eliminate spurious infections from eating livers containing the eggs
-eggs are deep golden brown, thick shelled, distinctly operculated,
measuring 38 to 45 u by 22 to 30 u containing a fully developed
miracidium

Treatment
-same as C sinensis
-praziquantel: 25 mg/kg TID for 2 consecutive days

Prevention and Control

-no effective measures of control
-fresh herbs collected from grazing areas for use as food for humans
should be washed to remove the ants

Scientific Common Infective Diagnostic

name name stage stage
F hepatica Sheep liver metacercaria Unembryonated
fluke ova
F gigantica Giant liver metacercaria Unembryonated
fluke ova
C sinensis Chinese liver metacercaria Embryonated
fluke ova
O felineus Cat liver fluke metacercaria Embryonated
ova
O vivernini metacercaria Embryonated
ova
D dendriticum Lancet fluke metacercaria Unembryonated
ova

Scientific 1st IH 2nd IH FH AFH

name
F hepatica snail Aquatic Herbivores, man
vegetation sheep
F gigantica snail Aquatic Camels, man
vegetation wild hogs,
cattle,
water
buffalo
C sinensis snail Freshwater man
fish
O felineus snail Freshwater Cats, dogs, man
fish fox,
wolves,
seals
O vivernini snail Freshwater Civet cat, man
fish cat, dog,
and other
fish eating
animals
D dendriticum snail ants sheep man